Should a patient suspected of having pericarditis, presenting with severe chest pain, difficulty breathing, or other concerning symptoms, be sent to the Emergency Room (ER) for immediate evaluation?

Should You Send a Patient with Suspected Pericarditis to the ER?

Yes, send all patients with suspected pericarditis to the emergency department—stable patients can go to the ED, chest pain unit, or cardiology ward, while unstable patients or those failing initial treatment require immediate transfer to an ED with critical care facilities. 1

Risk Stratification Determines Destination

The European Society of Cardiology provides clear guidance on where to send these patients based on their clinical stability:

Stable Patients

• Transfer to emergency departments, chest pain units, or cardiology wards if the patient responds rapidly to initial treatment 1
• These patients need facilities where echocardiography and pericardiocentesis are available, as pericarditis can progress to tamponade 1
• Stable uncomplicated pericarditis requires no specific pre-hospital management beyond pain relief with paracetamol or opiates 1

Unstable Patients or Treatment Failures

• Transfer to emergency departments with critical care facilities and/or intensive cardiac care units is highly recommended for unstable patients or those who fail to respond to initial treatment 1
• This includes patients with severe chest pain, difficulty breathing, hemodynamic instability, or signs suggesting possible tamponade 1

Why Every Suspected Pericarditis Case Needs Hospital Evaluation

Cannot Confirm Diagnosis Without Hospital Resources

• Positive diagnosis requires biological signs of inflammation and possible pericardial effusion on echocardiography, which cannot be confirmed in the outpatient setting 1
• The American College of Cardiology recommends ordering inflammatory markers and considering echocardiography for suspected pericarditis 2

Risk of Life-Threatening Complications

• Pericarditis can progress to cardiac tamponade (<3% of cases) or constrictive pericarditis (<0.5%), both potentially life-threatening 3
• Purulent pericarditis carries a high fatality rate and is invariably deadly without antibiotics 4
• Some patients develop multiple life-threatening complications including tamponade and shock requiring urgent intervention 5

Mimics STEMI on ECG

• It is critical to consider pericarditis in every patient in whom fibrinolysis is considered for presumed STEMI 1
• Pericarditis can show diffuse ST segment elevation on ECG (25-50% of cases), potentially leading to inappropriate fibrinolytic therapy if not properly evaluated 3
• The American Heart Association recommends obtaining an ECG within 10 minutes of arrival to evaluate for STEMI or other concerning findings 2

Common Pitfalls to Avoid

Don't Be Falsely Reassured by "Typical" Pericarditis Features

• Even with classic pleuritic chest pain that worsens when supine and improves leaning forward, patients still need hospital evaluation 1
• While these features suggest pericarditis, life-threatening causes must be excluded first 6

Don't Delay Transfer for Office-Based Testing

• If you suspect pericarditis in the office setting, send the patient to the ED rather than attempting to complete workup in your office 2, 6
• The American College of Cardiology recommends measuring cardiac troponin as soon as possible in all patients with acute chest pain and suspected ACS 2

Watch for High-Risk Features Requiring Immediate Action

• Hemodynamic instability (heart rate >130 or <40, systolic BP <90 mmHg) 1
• Respiratory distress (respiration rate >25, oxygen saturation <90%) 1
• Signs of tamponade: jugular vein distension, muffled heart sounds, pulsus paradoxus 7
• Fever with pericarditis may indicate purulent pericarditis requiring emergent intervention 4

Clinical Algorithm

Step 1: Assess Stability

• Check vital signs, oxygen saturation, and look for signs of tamponade 1
• Obtain ECG if immediately available, but don't delay transfer 2

Step 2: Determine Transfer Destination

• Unstable or high-risk features present? → Transfer by EMS to ED with critical care facilities/ICU 1
• Stable with typical pericarditis features? → Transfer to ED, chest pain unit, or cardiology ward 1

Step 3: Pre-Hospital Management (if applicable)

• Provide pain relief with paracetamol or opiates as needed 1
• No other specific management recommended during transport 1

The bottom line: pericarditis accounts for 5% of non-ischemic chest pain ED visits and requires hospital resources for diagnosis confirmation and complication monitoring 4, 5, 3. Even "stable" pericarditis needs evaluation in a facility equipped for echocardiography and potential pericardiocentesis 1.